Teriparatide products — Medical Mutual

Initial criteria

• Patient has a T-score at or below -2.5 at lumbar spine, femoral neck, total hip, and/or 33% radius (wrist) OR has had an osteoporotic or fragility fracture OR has low bone mass (T-score between -1.0 and -2.5 at lumbar spine, femoral neck, total hip, and/or 33% radius) and is determined to be at high risk for fracture by physician
• AND patient has tried one oral bisphosphonate and had an inadequate response after 12 months OR fracture while receiving therapy OR experienced intolerability; OR patient cannot take oral bisphosphonate due to inability to swallow, remain upright, or pre-existing GI condition; OR patient has tried ibandronate injection (Boniva) or zoledronic acid injection (Reclast); OR patient has severe renal impairment (CrCl <35 mL/min), chronic kidney disease, or has had an osteoporotic/fragility fracture
• AND use of teriparatide and/or Tymlos does not exceed 2 years per lifetime

Reauthorization criteria

• Continuation is allowed if therapy has not exceeded a maximum lifetime duration of 2 years.

Approval duration

1 year (initial); 1 year (reauth); max 2 years total